Clinical Review QC Auditor

Ultipro; Fort Worth (TX); Hybrid; USD 70,000 - 95,000; Full time

Job summary

CERIS in Fort Worth, TX is seeking a DRG Quality Control/Clinical Auditor to perform DRG validation reviews of medical records and documentation. This remote role requires ICD-10-CM/PCS expertise, strong communication, and knowledge of payer rules (Medicare/Medicaid).

Licensure as RN or LVN preferred with 2+ years DRG auditing experience. Ideal candidates have clinical knowledge of disease processes and ability to work independently in a fast-paced environment, with a focus on accurate

Qualifications

• LVN or RN license in the state of employment preferred.
• Experience in the OR, ICU, or ER as an RN highly preferred.
• Minimum 2 years DRG Quality Auditing experience in hospital or health plan; National Coding Certification required (AHIMA or AAPC).
• Extensive hands-on ICD-10-CM/PCS experience required.

Responsibilities

• Review medical records to determine accuracy of billing through verification of coding and review of supporting clinical documentation.
• Check for physician's notes supporting the DRGs assigned.
• Conduct audits to ensure accurate reimbursement and identify potential savings.
• Review previously conducted audits to ensure accurate coding and identify potential savings.
• Review all opportunities sent to customers for complete and correct information.
• Demonstrated knowledge of ICD-10-CM codes, PCS and DRG coding; payer rules incl. Medicare/Medicaid.
• Understand and comply with internal and external policies.
• HIPAA Privacy and Security Rules knowledge.
• Assist Quality Control team and medical director with appeals, rebuttals, etc.
• Notify leadership of issues or concerns in timely manner.
• Additional duties as assigned.

Skills

DRG coding

ICD-10-CM/PCS

Coding guidelines

Communication skills

HIPAA knowledge

Independent work

Attention to detail

MS Office

DRG expertise

Education

RN or LVN license

National Coding Certification (AHIMA/AAPC)

Tools

Microsoft Office

Job description

CERIS in Fort Worth, TX is seeking a DRG Quality Control/Clinical Auditor. The Diagnostic Related Groups (DRG) Clinical Auditor will be responsible for performing DRG validation (clinical/coding) reviews of medical records and/or other documentation. This role will determine correct DRG/coding as defined by review methodologies specific to the type of review. This involves completing medical record reviews, accurately documenting findings and non-findings and providing clinical/policy/regulatory support for the determination. This role will utilize their experience with ICD-10-CM & PCS coding guidelines, the ability to understand modern pharmacology, disease management and clinical intervention procedures. The ideal DRG Clinical Auditor candidate has strong written and verbal communication skills, clinical knowledge of disease processes, and knowledge of medical necessity rules.

This is a remote position.

ESSENTIAL FUNCTIONS & RESPONSIBILITIES:

• Review medical records to determine accuracy of billing through verification of coding and review of supporting clinical documentation
• Check for physician's notes supporting the DRGs assigned
• Conduct audits to ensure accurate reimbursement and identifying potential savings
• Review previously conducted audits to ensure accurate coding and identifying potential savings
• Review all opportunities sent to the customers for complete and correct information
• Demonstrated knowledge of ICD-10-CM codes, PCS and DRG coding, understanding of payer rules and regulations, including Medicare and Medicaid
• Understand and comply with all internal and external policies
• Working knowledge of HIPAA Privacy and Security Rules
• Assist Quality Control team and medical director with appeals, rebuttals, etc.
• Notify leadership of any issues or concerns in a timely manner
• Additional duties as assigned

KNOWLEDGE & SKILLS:

• Expert knowledge of application of current Official Coding Guidelines and Coding Clinic citations
• Solid knowledge and understanding of clinical criteria documentation requirements used to successfully substantiate code assignments
• Proficient understanding of Medicare, CMS guidelines and ICD-10 coding guidelines
• Effective and professional communication skills, both verbal and written
• Ability to work independently and in a team environment
• High attention to detail
• Must possess critical thinking skills
• Ability to multi-task and assist with team coverage and provide support when needed
• Ability to build relationships both internally and externally
• Ability to work in a fast-paced environment
• Demonstrated proficiency in basic computer skills and typing
• Proficiency with Microsoft Office
• Proficient in both MS and APR DRG methodology preferred

EDUCATION & EXPERIENCE:

• LVN or RN license in the state of employment preferred
• Experience in the OR, ICU, or ER as an RN highly preferred
• Required minimum of 2 year of recent DRG Quality Auditing experience in a hospital setting, or health plan. National Coding Certification required through either AHIMA (preferred) or AAPC
• Extensive hands-on ICD-10 CM / PCS experience required

PAY RANGE:

CorVel uses a market based approach to pay and our salary ranges may vary depending on your location. Pay rates are established taking into account the following factors: federal, state, and local minimum wage requirements, the geographic location differential, job-related skills, experience, qualifications, internal employee equity, and market conditions. Our ranges may be modified at any time.

For leveled roles (I, II, III, Senior, Lead, etc.) new hires may be slotted into a different level, either up or down, based on assessment during interview process taking into consideration experience, qualifications, and overall fit for the role. The level may impact the salary range and these adjustments would be clarified during the offer process.

In general, our opportunities will be posted for up to 1 year from date of posting, or until we have selected candidate(s) to fulfill the opening, whichever comes first.

ABOUT CERIS:

CERIS, a division of CorVel Corporation, a certified Great Place to Work Company, offers incremental value, experience, and a sincere dedication to our valued partners. Through our clinical expertise and cost containment solutions, we are committed to accuracy and transparency in healthcare payments. We are a stable and growing company with a strong, supportive culture along with plenty of career advancement opportunities. We embrace our core values of Accountability, Commitment, Excellence, Integrity and Teamwork (ACE-IT!).

A comprehensive benefits package is available for full‑time regular employees and includes Medical (HDHP) w/Pharmacy, Dental, Vision, Long Term Disability, Health Savings Account, Flexible Spending Account Options, Life Insurance, Accident Insurance, Critical Illness Insurance, Pre‑paid Legal Insurance, Parking and Transit FSA accounts, 401K, ROTH 401K, and paid time off.

CorVel is an Equal Opportunity Employer, drug free workplace, and complies with ADA regulations as applicable.

Equal Opportunity Employer
This employer is required to notify all applicants of their rights pursuant to federal employment laws.For further information, please review the Know Your Rights notice from the Department of Labor.